What do sparkplugs have to do with atrial fibrillation?

In the following interview, Frauke Fiegl, Chair of the Board of Management of DKV Deutsche Krankenversicherung AG and of ERGO Krankenversicherung AG, speaks with Prof. Marc Horlitz, Chief Physician for Cardiology, Electrophysiology and Rhythmology at Porz am Rhein Hospital, about cardiac health, prevention, and how wearables can support the early detection of atrial fibrillation. Prof. Marc Horlitz is one of our roughly 100 DKV Best Care Top Experts, who our Best Care insureds can turn to for a second opinion and detailed recommendations on further therapy in connection with serious illnesses.

Prof. Horlitz, thank for your taking the time to speak with us about coronary health and prevention, a topic that many people associate with high blood pressure, atherosclerosis and heart attacks. In this regard, what is the role of atrial fibrillation, which is now affecting a rapidly growing number of patients?

The likelihood of atrial fibrillation rises with the risk factors you just mentioned. Today, ca. 2 million people living in Germany have already been affected and the number rises every year.

What exactly is atrial fibrillation?

Atrial fibrillation is a condition in which the heart’s normal rhythm is disrupted. A normal, regular heartbeat is produced by the sino-atrial node, a “healthy sparkplug” inside our hearts that sets the tact. The sequence of heartbeats determines the heart’s rhythm, which is referred to as sinus rhythm among the medical community. During atrial fibrillation, there are additional “false sparkplugs”, which arise in the left atrium. They are produced by the accumulation of connective tissue in the atrium. You could compare the process with a “great stone in the sea”: the waves crash against it, sending up spray. In a similar way, electrical impulses within the heart crash against the connective tissue, leading to atrial fibrillation.

Are we all equally at risk?

With a high degree of probability, genetic factors are what affect the risk of atrial fibrillation most. But we still don’t know all of the loci for the production of atrial fibrillation. As genetic tests become more advanced, at some point we’ll likely be able to detect an increased risk early on. Further risk factors include high blood pressure and sleep apnoea, which is characterised by dangerous pauses in breathing during sleep, as a result of which the body can’t take in enough oxygen. In addition, inflammation caused by diabetes, infections, pulmonary or cardiac muscle inflammation can increase the risk of additional connective tissue forming in the left atrium.

Unfortunately there’s no single answer as to why someone experiences atrial fibrillation. There are a wide range of risk factors – a major one being epigenetics, i.e. environmental factors and lifestyle aspects like stress that affect the vegetative nervous system. They can all lead to the formation of “false sparkplugs”.

That’s very interesting. I can see why you’re so focused on the topic.

Yes, absolutely. Atrial fibrillation has become a big part of my life!

Let’s move on to the next question: my pulse increases, my heart races or skips a beat. How can I tell whether or not it’s atrial fibrillation? Can you have atrial fibrillation and not know it?

Atrial fibrillation can only be diagnosed and defined with an ECG (electrocardiogram), a technique that measures the heart’s electrical activity. If you take your pulse at your wrist and notice that it’s irregular, you should see a doctor. With an ECG, they can easily tell whether or not it’s actually a case of atrial fibrillation. Other symptoms can include shortness of breath, heart failure and palpitations. Ca. 40% of atrial fibrillation patients don’t notice any symptoms. And that’s the real risk, since during fibrillation the blood can become “churned up” in the left atrium, which can lead to blood clots and, in turn, to strokes. That’s why early detection of atrial fibrillation is so important, as those affected need to quickly be administered blood thinner to reliably prevent stroke.

You said that in many cases, atrial fibrillation goes unnoticed. Are devices like smartwatches and other wearables useful helpers?

In the future, wearables will take on an essential role in the detection of atrial fibrillation. I highly recommend that everyone start familiarising themselves with these cutting-edge technologies right away. Personally, I’ve had a smartwatch for several years now and couldn’t be happier. The ECGs that can be derived from wearables are so good that, on this basis alone, doctors can determine whether or not it’s a case of atrial fibrillation with 99% certainty. Wearables are an excellent way of recognising atrial fibrillation in a timely manner.

In other words, they’re helpful when it comes to detecting potential atrial fibrillation, and then you need an expert for the diagnosis.

Exactly. Then you need a doctor and to quickly receive blood thinner, since the worst outcome of atrial fibrillation is a stroke, which can be avoided if action is taken in time.

That leads to my next question: what should I do if I suspect I’m experiencing atrial fibrillation, and what are the therapeutic options?

If there’s a suspicion, you have to check it out. It’s considered to be atrial fibrillation when the arrhythmia continues for at least 30 seconds and also shows up in an ECG. If that’s the case, you need to take blood thinner. On the basis of a risk score, the probability of stroke is calculated, i.e. the various risk factors, like high blood pressure, diabetes and age, are all assessed. Then the decision is made as to whether or not the patient needs to take blood thinner for the rest of their life. In addition, beta blockers can be used to slow the pulse, and electrical cardioversion to restore the normal heart rhythm. In the next step, the patient discusses the further treatment with their family doctor, cardiologist or electrophysiologist.

Special-purpose atrial fibrillation centres, which employ catheter ablation, can treat atrial fibrillation with an 80% success rate. Catheter ablation is a safe and minimally invasive technique used to destroy, by freezing or heating, the heart’s “false sparkplugs”. It’s essential that ablation be done as early as possible. As such, patients shouldn’t wait until the atrial fibrillation becomes chronic, and should take steps to treat it while it’s still sporadic, e.g. with balloon cryoablation.

What constitutes “sporadic”? Once or twice a year? Once or twice a month?

That’s a very important question. If I’d only had atrial fibrillation once in the span of two years, I would be a bit more hesitant to have an operation, but if it happens more than once a year, ablation is advisable, since with every additional fibrillation event, the connective tissue that causes it can grow further. It’s just like weeds in your garden, which constantly grow if they’re not pulled out in time. Once a critical amount of this “weed tissue” in the heart is exceeded, ablation will no longer work. Accordingly, it’s important to discuss this with your doctor early on to determine the best timing for the procedure in your individual case.

Are there sensible measures that can be taken to avoid atrial fibrillation?

Yes and no. We can’t do anything about our genes, but there’s quite a bit that we can do to reduce the likelihood of atrial fibrillation. I recommend doing all you can to reduce the established risk factors for cardiac and vascular disease. That includes regular blood pressure and blood sugar tests. And of course, plenty of exercise and switching to a Mediterranean diet can help you stay or become fit and trim. As I said before, it’s a good idea to take your pulse at your wrist from time to time, to check for a regular heartbeat. But today, being diagnosed with atrial fibrillation no longer has to be the end of the world. 20 years ago, ablation was still an experimental technique; that’s hardly the case today. In the major cardiac care centres, atrial fibrillation can now be treated with an 80% success rate using ablation. The procedure takes about an hour, during which the patient is sedated. Afterwards they stay at the hospital overnight and can be released again the next day. In this regard, patients should check that the atrial fibrillation care centre has been certified by the German Cardiac Society (Deutsche Gesellschaft für Kardiologie). Porz am Rhein Hospital in Cologne has been certified for years. We were one of the first hospitals in the Rhineland to be certified, and I found the certification process extremely challenging, because every last detail was assessed. So when a patient goes to a certified atrial fibrillation care centre, they can truly rest assured that the ablation will be done in keeping with the highest quality standards.

Just one last question: from a medical standpoint, what would be your “number one” piece of advice for our insureds?

Exercise, a healthy diet and a positive attitude – that’s the best prevention for a healthy life.

Thank you very much for the interesting insights into atrial fibrillation and your tips on how our insureds can stay healthy.